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Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia Trichiasis Poliosis Madarosis Ingrown Cilia Dermatochalaisis Blepharochalaisis Herniation.

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Presentation on theme: "Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia Trichiasis Poliosis Madarosis Ingrown Cilia Dermatochalaisis Blepharochalaisis Herniation."— Presentation transcript:

1 Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia Trichiasis Poliosis Madarosis Ingrown Cilia Dermatochalaisis Blepharochalaisis Herniation of Orbital Fat Papilloma/Verruca Cutaneous Horn/Tag Seborrheic Keratosis Keratocanthoma Dermoid Sebaceous Gland Cysts Sudoriferous Cysts Nevus

2 Dear Dr. Golden Eye: My friends say that I am super hyper and that I do not like things to pass me by. Recently, my new girlfriend took a picture of me when I was sleeping and posted the picture below. Now that I think about it, my eyes do feel a bit irritated. What’s going on? What are the common causes of my condition? Clue me on your evaluation of me? What can you do for me (treatment / management)? Signed: Peek-a-boo

3 Lagophthalmos Inability to completely close the lids; remain open 2-5mm Inability to completely close the lids; remain open 2-5mm Significance Significance –Usually results in exposure of the globe causing epithelial dessication; c/o dry, scratchy eye, possibly secondary infection and/or corneal ulcers. Sterile ulcers can result

4 Common causes/classification Common causes/classification –Paralytic of orbicularis (CN VII palsy) - Bell's palsy –Orbital Corneal apex more anterior than normal (keratoconus) Corneal apex more anterior than normal (keratoconus) Differential diagnosis includes: Differential diagnosis includes: –Globe displaced forward (retrobulbar mass, thyroid disease) Larger than normal axial length Larger than normal axial length Shallow orbit (rare) Shallow orbit (rare)

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6 –Neurogenic Stimulation of retractors (Mueller's muscle) Stimulation of retractors (Mueller's muscle) Hyperthyroidism (Grave's disease) is most common cause Hyperthyroidism (Grave's disease) is most common cause –Mechanical Scarring Scarring Active lid disease Active lid disease –Physiological or nocturnal lagophthalmos

7 Signs and symptoms Signs and symptoms –During sleep lids not in apposition -> tear film evaporation - epithelial dessication –Symptoms of dry, scratchy, irritated eye upon awakening –Look for punctate epitheliopathy across inferior cornea - this may not be present or may be positioned elsewhere –Check for Bell's phenomenon (although this is probably unrelated to position of globe during sleep)

8 –Check passive lid closure, may need to recline patient –Ask spouse if patient sleeps with eyes open –Check whether blink is complete. Check blink rate –Evaluate for anterior segment diseases, especially blepharitis

9 Management Management –Mild symptomatic lagophthalmos Artificial tears PRN (Q1H to QID recommended) Artificial tears PRN (Q1H to QID recommended) Bland ophthalmic ointment HS if needed (Lacrilube) Bland ophthalmic ointment HS if needed (Lacrilube) –Moderate Artificial tears PRN, ophthalmic lubricants hs Artificial tears PRN, ophthalmic lubricants hs Tape from cheek to brow/forehead while pulling lower lid up Tape from cheek to brow/forehead while pulling lower lid up Moisture chamber (Saran Wrap sealed with tape - Transpore surgical tape or Dermocel) Moisture chamber (Saran Wrap sealed with tape - Transpore surgical tape or Dermocel)

10 –Use broad spectrum antibiotics (TABLES on pages 14 and 15) if significant corneal epithelial dessication or damage (to prevent secondary infection) –Surgery (tarsorrhaphy) –Must have regular follow up to rule out infection or serious drying; every 3 months or more frequently.

11 Blepharospasm Involuntary contraction of orbicularis Involuntary contraction of orbicularis Generally bilateral and symmetric, though onset may be unilateral Generally bilateral and symmetric, though onset may be unilateral Older individuals, females > males Older individuals, females > males

12 Severity progresses over 6 months to 3 years Severity progresses over 6 months to 3 years Does not occur during sleep Does not occur during sleep Fatigue and stress may increase intensity Fatigue and stress may increase intensity Unknown cause, possibly due to chemical imbalance and/or misfiring of neurons of basal ganglia Unknown cause, possibly due to chemical imbalance and/or misfiring of neurons of basal ganglia

13 Signs and Symptoms Signs and Symptoms –Involuntary lid closure –Facial muscles (jaw, tongue, lower face, mouth) –May be so severe as to cause secondary tempero-mandibular joint syndrome (TMJ) –Various sensory "tricks" may suppress the severity of the contractions Commonest is placing a finger at the lateral margin of the orbit Commonest is placing a finger at the lateral margin of the orbit Others: coughing, yawning, talking, humming, or singing Others: coughing, yawning, talking, humming, or singing

14 –Differential diagnosis very complicated Ocular disease Ocular disease Myokymia Myokymia Tardive dyskinesia caused by antipsychotic medications (Prolixin, Haldol) Tardive dyskinesia caused by antipsychotic medications (Prolixin, Haldol) –Various neurological disorders –Functional (hysterical)

15 Treatment Treatment –Counseling since patient is quite self- conscious –Counseling for depression since many activities of daily life and work are interrupted –Medications interfering with nerve conduction are variably, but not consistently successful

16 –Botulin A toxin injections Interferes with neural transmission Interferes with neural transmission Relief of symptoms averages 3 months Relief of symptoms averages 3 months Typical side effects: Typical side effects: –Ptosis –Subcutaneous hemorrhage at injection site –Dry eyes –Double vision –Exposure keratitis Side effects resolve as toxin wears off Side effects resolve as toxin wears off

17 Onset of action after injection: 2-3 days Onset of action after injection: 2-3 days Full benefit: 5 days Full benefit: 5 days Peak effect: 2-4 weeks Peak effect: 2-4 weeks Duration of clinical benefit: 3-4 months, but can vary from few weeks to 6 months Duration of clinical benefit: 3-4 months, but can vary from few weeks to 6 months

18 –Surgery Myectomy and/or partial neurectomy Myectomy and/or partial neurectomy Myectomy removes squeezed muscles in upper lid, eyebrows, forehead, and base of nose Myectomy removes squeezed muscles in upper lid, eyebrows, forehead, and base of nose Neurectomy consists of resection and removal of small facial nerve branches innervating orbicularis Neurectomy consists of resection and removal of small facial nerve branches innervating orbicularis –Referral to national support groups and organizations for individuals with blepharospasm

19 Blepharoclonus Exaggerated reflex blinking characterized by increased blink rate or length of lid closure time Exaggerated reflex blinking characterized by increased blink rate or length of lid closure time Causes Causes –Often no cause found –Commonly in children 5-10 years old with no apparent cause but parents are distressed - this is most common presentation

20 Evaluation Evaluation –Workup is the same as for blepharospasm - rule out anterior segment disease, irritation, fb, etc.; complete eye exam Management Management –Reassurance - (self limited disorder) –Consult with neurologist if desired –Numerous surgical procedures to interrupt CN VII have been tried

21 Myokymia Eyelid tic or twitch Eyelid tic or twitch Mild to moderate fasiculations of orbicularis Mild to moderate fasiculations of orbicularis Signs and symptoms Signs and symptoms –Patient aware of annoying twitch Unilateral Unilateral More often lower lid More often lower lid –Examiner generally sees nothing wrong

22 Multiple causes Multiple causes –Fatigue, lack of sleep –Stress, anxiety, tension –Anterior segment irritation –Light dazzle –Anemia, nutritional deficiency –Excessive use of tobacco or alcohol –Anticholinesterases used therapeutically (physostigmine, neostigmine, echothiophate) –Rare: M.S., myasthenia gravis, trigeminal neuralgia

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24 Treatment Treatment –Reassurance –Rule out irritation, infection, inflammation –Consultation with family MD or psychologist to evaluate stress, tension, etc. –Pharmacological treatment Topical antihistamine eyedrops (SEE TOPICAL ANTIHISTAMINE TABLE on page 21) Topical antihistamine eyedrops (SEE TOPICAL ANTIHISTAMINE TABLE on page 21)  QID x 1 week  BID x 1 week  Re-eval

25 Stubborn cases may warrant oral quinine, mg, QD to TID; CONTRAINDICATED in pregnant women, since increases risk of abortion Stubborn cases may warrant oral quinine, mg, QD to TID; CONTRAINDICATED in pregnant women, since increases risk of abortion Oral antihistamine Oral antihistamine –Benadryl

26 Dirty water = tonic water with lime Dirty water = tonic water with lime Drink prn Drink prn

27 Trichiasis Lashes touch globe Lashes touch globe Causes Causes –Entropion –Growths on lid margin –Lid trauma –Scarring of conjunctiva (trachoma, Stevens-Johnsons syndrome) –Blepharitis is most common

28 Signs and symptoms Signs and symptoms –Discomfort or pain, foreign body sensation, injection –Chronic tearing due to foreign body sensation –May traumatize the epithelium corneal epithelial defects - infections, ulcers corneal epithelial defects - infections, ulcers damage and scarring of conj or cornea damage and scarring of conj or cornea –Can cause vision loss due to corneal scarring

29 Evaluation Evaluation –Find the underlying cause of the trichiasis if possible - blepharitis is a common underlying cause –Careful slit lamp evaluation for both trichiasis and epith damage –Use fluoroscein - check for staining; epithelial damage

30 Management Management –Epilate in-turning lashes Forceps or epilation tweezers Forceps or epilation tweezers Soak tools in zephiran chloride solution (1:3OOO) with anti-rust tablets added Soak tools in zephiran chloride solution (1:3OOO) with anti-rust tablets added Can anesthetize lid Can anesthetize lid Firmly grasp lash at its base and pluck Firmly grasp lash at its base and pluck Do not clip lashes Do not clip lashes

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32 –Lashes grow back Children: 2-4 weeks Children: 2-4 weeks Adults: 4-8 weeks Adults: 4-8 weeks –Cauterization of follicles generally gives poor results –Electrolysis destroys lash follicles; successful but quite painful

33 –If > 1/3 of lashes are turned in, surgery is warranted rather than electrolysis Cryosurgery Cryosurgery Argon laser photocoagulation Argon laser photocoagulation –Regular use of ocular lubricants Q1H to QID –Prophylactic broad spectrum antibiotic coverage

34 Poliosis Whitening of lashes Whitening of lashes Usually due to staph blepharitis Usually due to staph blepharitis Vitiligo is not due to staph Vitiligo is not due to staph If both poliosis and vitiligo evaluate internal ocular health (c/o uveitis), if negative get dermatology consult If both poliosis and vitiligo evaluate internal ocular health (c/o uveitis), if negative get dermatology consult

35 Madarosis Lash loss Lash loss Causes Causes –Very common cause is staph blepharitis –Trichotellomania (neurotic pulling of lashes)

36 Evaluation Evaluation –Look for any evidence of staph blepharitis –Inquire about history of infection…eg Chicken Pox –Rule out anterior segment disease of any kind (especially staph)

37 Management Management –Treat blepharitis if present –Could photodocument to monitor therapy –If caused by trichotellomania seek psychological counseling seek psychological counseling mascara use to minimize pulling mascara use to minimize pulling

38 Ingrown Cilia Eyelash grown into the epidermis of the lid Eyelash grown into the epidermis of the lid Can be directed against globe (trichiasis) Can be directed against globe (trichiasis) –may have foreign body sensation Look for more than a single ingrown cilia Look for more than a single ingrown cilia Look for cause, lid trauma and scarring Look for cause, lid trauma and scarring

39 Management Management –Cut lash near follicle –Remove distal portion of lash –Epilate remainder of lash –Prophylaxis with antibiotic *

40 Dermatochalaisis Redundancy of skin of the upper lid such that it drapes downward over lid margin. May look like ptosis - hold the redundant skin flap up Redundancy of skin of the upper lid such that it drapes downward over lid margin. May look like ptosis - hold the redundant skin flap up Middle aged to elderly patient; bilateral Middle aged to elderly patient; bilateral May be familial tendency May be familial tendency May have herniation of orbital fat through the orbital septum causing puffy, "swollen“ appearance May have herniation of orbital fat through the orbital septum causing puffy, "swollen“ appearance

41 Evaluation Evaluation –Usually quite easy to notice and diagnose (just "baggy" eyelids) –Watch for true ptosis and for lid edema Management Management –If no trichiasis and no field loss the problem is cosmetic only - reassure the patient –If trichiasis, treat it. (Consider surgery - cryo, electrolysis, etc.) *

42 If field loss and desire to obtain cosmetic improvement, do a careful formal visual field evaluation with and without lids held to document functional vision defect (10˚ difference in VF loss). Insurance needs this in most cases to allow a claim for blepharoplasty If field loss and desire to obtain cosmetic improvement, do a careful formal visual field evaluation with and without lids held to document functional vision defect (10˚ difference in VF loss). Insurance needs this in most cases to allow a claim for blepharoplasty Surgery - blepharoplasty remember VF necessary with and without lid held to obtain insurance funding Surgery - blepharoplasty remember VF necessary with and without lid held to obtain insurance funding Referral to oculoplastic specialist or cosmetic surgeon Referral to oculoplastic specialist or cosmetic surgeon

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44 Blepharochalaisis Younger to middle aged patient with baggy lids secondary to recurrent swelling of lids due to recurrent inflammation or edema Younger to middle aged patient with baggy lids secondary to recurrent swelling of lids due to recurrent inflammation or edema These recurrences of edema result in stretching of periorbital skin, loss of elasticity These recurrences of edema result in stretching of periorbital skin, loss of elasticity

45 Superior lid drapes over lid margin in many cases Superior lid drapes over lid margin in many cases May mimic ptosis. Be sure to rule out true ptosis. Note that a ptosis (not of neurogenic origin) can result from damage to the levator aponeurosis. May be some cases with familial tendency May mimic ptosis. Be sure to rule out true ptosis. Note that a ptosis (not of neurogenic origin) can result from damage to the levator aponeurosis. May be some cases with familial tendency

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47 Evaluation Evaluation –Rule out active cause, i.e. lid mass, edema, inflammation –Rule out ptosis –Look for underlying cause - recurrent edema due to allergy, high BP, kidney disease

48 Management Management –Treat any active cause –Cool compressed during swelling may help to decrease –Steroids usually not helpful –Consult with physician may help to rule out allergic disease, cardiac or renal diseases if suspected

49 –If cosmetically displeasing to patient - VF's and referral to plastic surgeon particularly oculoplastics specialist for blepharoplasty –May need medical consult to determine cause of recurrent edema, i.e., rule out cardiac, renal causes and angioneurotic edema

50 Herniation of Orbital Fat As orbital septum atrophies with age orbital fat herniates through small dehistences resulting in a soft mass usually located in upper lid medially As orbital septum atrophies with age orbital fat herniates through small dehistences resulting in a soft mass usually located in upper lid medially May get referrals to evaluate "tumor“ May get referrals to evaluate "tumor“ Occurs in elderly (secondary to weakening of orbital septum involutional change) Occurs in elderly (secondary to weakening of orbital septum involutional change) Presents as localized (inner canthus) soft, spongy mass within lid, anterior to tarsal plate Presents as localized (inner canthus) soft, spongy mass within lid, anterior to tarsal plate

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52 Evaluation Evaluation –Generally easily differentiated from lid or orbital growth (or lid edema) –Pressure to globe results in further herniation of orbital fat in front of the septum Management Management –Reassure patient –Cosmetic surgery, if desired –Excision of orbital fat plus blepharoplasty for dermatochalaisis if present

53 Papilloma Benign Epithelial Tumor A common benign overgrowth of the epidermal portion of the skin of the eyelid (mainly the squamous epith) A common benign overgrowth of the epidermal portion of the skin of the eyelid (mainly the squamous epith) Can have vascular core Can have vascular core Benign growths but varied appearance Benign growths but varied appearance Malignancies may look like these but are generally clinically differentiated on appearance Malignancies may look like these but are generally clinically differentiated on appearance May be caused by virus (if so called verruca); more common in young May be caused by virus (if so called verruca); more common in young Can have numerous presentations; can be pigmented, variety of colors Can have numerous presentations; can be pigmented, variety of colors

54 Types Types –Non-viral Usually in elderly Usually in elderly –Viral Verruca Verruca Verruca is a form of papilloma Verruca is a form of papilloma –Verruca plana - flat top –Verruca vulgaris - angular, raised, broad stalk –Verruca digitala - narrow stalk, cauliflower-like

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56 Signs/symptoms Signs/symptoms –Usually asymptomatic –Growth Viral - fairly quick Viral - fairly quick Non-viral-slow Non-viral-slow –Color Various colors Various colors Surface usually rough (keratinized epithelium) but may be smooth, not eroded, ulcerated Surface usually rough (keratinized epithelium) but may be smooth, not eroded, ulcerated

57 Can be slowly growing, have vascular core, do not usually erode in center. Usually near lid margins at mucocutaneous junction Can be slowly growing, have vascular core, do not usually erode in center. Usually near lid margins at mucocutaneous junction Vascular core Vascular core

58 Evaluation Evaluation –Rule out neoplastic growth, if possible, by looking for the following: Look for rapid growth, color change Look for rapid growth, color change If on lid margin, no cilia at the location If on lid margin, no cilia at the location Bleeding highly unlikely unless papilloma is traumatized Bleeding highly unlikely unless papilloma is traumatized Vascularization - not present on surface of papilloma Vascularization - not present on surface of papilloma

59 Surface is often rough but not eroded or ulcerated. Papilloma can occasionally outgrow blood supply resulting in keratinization or necrosis -> erosion, ulceration Surface is often rough but not eroded or ulcerated. Papilloma can occasionally outgrow blood supply resulting in keratinization or necrosis -> erosion, ulceration

60 Management Management –Generally no treatment indicated, reassure –Cosmetic treatment only if desired (excision) –Can produce local lash misdirection and resultant trichiasis –Easily excised with scissors if pedunculated. If large or flat, refer for surgical excision

61 –Refer to dermatologist or ophthalmologist if highly suspicious or take photos and follow up in one month –If new lesion, carefully evaluate for evidence of malignant characteristics; photograph and follow-up in one to three months –If old, follow up yearly

62 –Excision techniques Scissors/scalpal technique Scissors/scalpal technique –i)Scissors or scalpal –ii)If base is small, clean area with alcohol wipe –iii)Anesthetize with topical proparacaine for > 1 minute

63 –iv)Grasp top with forceps and lift –v)Cut base with scalpal or scissors –vi)Curved scissors are best –vii)Apply pressure for bleeding –viii)Cover with antibiotic ointment (TABLE page 14) –ix)Follow up in one day

64 Chemical technique Chemical technique –i)Clean area with alcohol wipe –ii)Topical anesthetic –iii)Surround papilloma with petroleum jelly –iv)Apply bichloroacetic acid to wooden tip of cotton swab - apply to lesion –v)Should turn lesion white immediately, later darkens, scab falls off in about one week

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68 Verruca (Wart) A papilloma in which papilloma inclusion bodies have been seen in the epith cells. Possibly all papillomas are viral in origin - caused by the human papilloma (wart) virus A papilloma in which papilloma inclusion bodies have been seen in the epith cells. Possibly all papillomas are viral in origin - caused by the human papilloma (wart) virus Viral papillomas tend to occur in children and young adults Viral papillomas tend to occur in children and young adults Transmission by direct or indirect contact and autoinoculation Transmission by direct or indirect contact and autoinoculation

69 Management Management –Spontaneous regression is likely - reassure and wait –Treat any associated conjunctivitis or keratitis with goal to prevent secondary bacterial infection –Excisional biopsy can be performed but can be followed by the spontaneous appearance of multiple viral papilloma –Cryotherapy should accompany excision if viral etiology suspected

70 Cutaneous horn or tag Form of papilloma probably, although may be keratinized Form of papilloma probably, although may be keratinized Management Management –Easily excised (see management of papilloma)

71 Seborrheic keratosis (not actinic keratosis) Benign, epithelial growth common in middle aged to older (some in children) Benign, epithelial growth common in middle aged to older (some in children) Common on trunk and head Common on trunk and head Can occur on eyebrow and lids Can occur on eyebrow and lids Sharply defined, slightly elevated, brown, plastered on lesions, brownish color - like a "brown plaque" on the skin Sharply defined, slightly elevated, brown, plastered on lesions, brownish color - like a "brown plaque" on the skin

72 Important point looks like it is tacked on or stuck onto surface of skin. Little invasion into epidermis, none into dermis Important point looks like it is tacked on or stuck onto surface of skin. Little invasion into epidermis, none into dermis Significance Significance –Not pre-malignant (actinic keratosis is) Management Management –Excision if desired –Easily removed for cosmetic reasons

73 Keratoacanthoma Keratoacanthoma Pseudocarcinomatous hyperplasia - benign growth Pseudocarcinomatous hyperplasia - benign growth Exposed usually hairy regions (such as head, face) of skin Exposed usually hairy regions (such as head, face) of skin Middle aged or older, usually Middle aged or older, usually Usually Caucasian Usually Caucasian Grows rapidly x 2-6 weeks then involutes in a few months or year Grows rapidly x 2-6 weeks then involutes in a few months or year Maximal size usually 1-2 cm Maximal size usually 1-2 cm

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75 Appearance Appearance –Raised lesion initially - dome-shaped nodule with central core like molluscum contagiosum Has central umbilicated apical region (composed of keratin) in a crater-like excavation Has central umbilicated apical region (composed of keratin) in a crater-like excavation Has elevated rolled borders. Mimics sq. cell ca and molluscum contagiosum Has elevated rolled borders. Mimics sq. cell ca and molluscum contagiosum

76 –Grows rapidly to 1-2 cm with pore expanded to display keratin filled crater –Growth stops, keratin plug is discharged leaving a pit. Mimics squamous cell carcinoma Significance Significance –Spontaneously regresses by involution but very often mistaken for squamous cell. Because of this appearance, usually excised during phase of involutional regression

77 Management Management –Reassure –Photograph if unsure and close follow-up –Excision if cosmetically desired Excision should be strongly considered because: Excision should be strongly considered because: –Most patients prefer not to wait for regression because of the poor cosmesis of these growths –BCC and SCC can (rarely) occur along the edges

78 –Excision and biopsy (all excised material should be biopsied) is recommended because of resemblance to SCC and BCC –BCC and SCC can (rarely) occur along the edges Recurrence Recurrence –Recurrence after excision is rare so if recurrence occurs, it was almost definitely BCC or SCC, not keratoacanthoma

79 Dermoid Benign Cystic Lesion Choriostomas, not neoplasms Choriostomas, not neoplasms Choriostoma arises during development from location of the lesion Choriostoma arises during development from location of the lesion Dermoids are congenital, developmental anomalies Dermoids are congenital, developmental anomalies Probably groups of surface ectodermal cells entrapped during development along lines of embryonic closure Probably groups of surface ectodermal cells entrapped during development along lines of embryonic closure

80 Appearance Appearance –Tend to be cystic in nature - "dermoid cyst“ –Usually superior temporal in location; usually adherent to periosteum of orbit –Skin slides over surface easily

81 Evaluation Evaluation –If dermoid is noted look for other congenital anomalies –Goldenhar's syndrome-dermoids on surface of globe often accompanied by lid coloboma and appendages on ears Management Management –Can be removed if desired for cosmetic reasons

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83 Sebaceous gland cysts Cysts in the glands of Zeiss (along lid margin) and/or in larger sebaceous glands (near eyebrows) Cysts in the glands of Zeiss (along lid margin) and/or in larger sebaceous glands (near eyebrows) Very common Very common Many possible locations: scalp, face, ears, back, axillary regions Many possible locations: scalp, face, ears, back, axillary regions

84 Types Types –Comedo (blackhead) Keratin plaque in follicle Keratin plaque in follicle –Milia (whitehead) Small whitish, slight elevated, cyst of the pilosebaceous gland Small whitish, slight elevated, cyst of the pilosebaceous gland On skin of lid, usually in groups On skin of lid, usually in groups

85 Appearance Appearance –Painless, benign, slow progression –Firm, rubbery, rounded, often moveable, yellowish or whitish color –Depth: Superficial (epithelial) - tend to be smaller < 10 mm Superficial (epithelial) - tend to be smaller < 10 mm Subcutaneous (epidermal) - tend to be large < 20 mm Subcutaneous (epidermal) - tend to be large < 20 mm

86 Management Management –Reassure, benign but can be removed for cosmetic reasons –Excision of superficial cysts – technique  a)Clean area with alcohol wipe  b)Apply topical anesthetic for ~ 1 minute  c)Incise with 18 to 27 gauge needle

87  d)Express contents  e)Apply pressure for bleeding  f)Cover with Polysporin ung  g)Follow-up in 1 day –Surgical excision for larger, deeper cysts

88 Sudoriferous cysts Elevated rounded lesions caused by blockage of the gland of Moll Elevated rounded lesions caused by blockage of the gland of Moll Common Common Appearance Appearance –May be < 2 mm in diameter –Localized at lid margin –Usually painless –Usually cause no problems –Cystic nature apparent in indirect/proximal illumination

89 Management Management –Reassurance, benign –Can be excised easily - technique a)Clean area with alcohol wipe a)Clean area with alcohol wipe b)Anesthetize surface for 1 minute b)Anesthetize surface for 1 minute c)Lance with 18 to 27 gauge needle c)Lance with 18 to 27 gauge needle d)Express material d)Express material e)Cover with Polysporin ung e)Cover with Polysporin ung f)Follow up in 1 day f)Follow up in 1 day

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91 Nevus (freckle) Benign melanotic lesions Overgrowth of melanin-containing cells in skin Overgrowth of melanin-containing cells in skin Can change with time and remain benign, however change ALWAYS suggests malignancy Can change with time and remain benign, however change ALWAYS suggests malignancy Flat, brownish, well defined borders Flat, brownish, well defined borders

92 Types Types –Junctional nevi a)FLAT or only slightly elevated a)FLAT or only slightly elevated b)Smooth surface b)Smooth surface c)Uniform light to medium brown c)Uniform light to medium brown d)Symmetrical borders d)Symmetrical borders e)Rarely become malignant e)Rarely become malignant

93 –Compound nevi a)Somewhat elevated, more so with age a)Somewhat elevated, more so with age b)Flesh colored or brown b)Flesh colored or brown c)Smooth or warty surface c)Smooth or warty surface d)Symmetric, uniformly round or oval d)Symmetric, uniformly round or oval

94 –Dermal nevi a)Raised, dome-shaped a)Raised, dome-shaped b)Brown or black, lighter with age b)Brown or black, lighter with age c)Smooth or warty surface c)Smooth or warty surface d)May have telangiectatic vessels on surface d)May have telangiectatic vessels on surface e)Exposed and prone to trauma from clothing e)Exposed and prone to trauma from clothing

95 Guidelines for recognition of normal nevi Guidelines for recognition of normal nevi a)(A)symmetrical: symmetric, matching halves if "folded" together; round or oval a)(A)symmetrical: symmetric, matching halves if "folded" together; round or oval b)Borders: regular, usually quite distinct b)Borders: regular, usually quite distinct c)Color: uniform within lesion, varies from very light brown to black c)Color: uniform within lesion, varies from very light brown to black

96  d)Diameter: < 6 mm  e)Elevation: fairly flat  f)Remain uniform in size, shape, and color  ABCDEF

97 Evaluation Evaluation –Careful history to document onset and progression –Size it!!! –If any doubt photodocument and follow very closely or better yet dermatology consult Management Management –Photograph carefully –Re-evaluate based on degree of suspicion –Only biopsy can definitely rule out melanoma. Any change demands a biopsy.


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